The defendant is charged [in count __]
with custodial interference in the first degree. The statute defining this
offense reads in pertinent part as follows:

a person is guilty of custodial
interference in the first degree when (he/she) commits custodial interference in
the second degree <insert appropriate subsection:>

§ 53a-97 (a) (1):
under circumstances which expose the (child / person) (taken or enticed from
lawful custody / held after a request by the lawful custodian) for (his/her)
return to a risk that (his/her) (safety will be endangered / health materially
impaired).

§ 53a-97 (a) (2):
by taking, enticing, or detaining the (child / person) out of this state.

For you to find the defendant guilty
of this charge, the state must prove the following elements beyond a reasonable
doubt:

Element 1 - Committed custodial
interferenceThe first element is that
the defendant committed custodial interference in the second degree. <Insert
instruction for underlying crime:>

Element 2 - Risk factorThe second element is that the
defendant committed this offense <insert as appropriate:>

under circumstances
that exposed <insert name of child or person taken> to a risk that
(his/her) (safety would be endangered / health materially impaired).

by taking, enticing
or detaining <insert name of child or person taken> out of this state.

Conclusion

In summary, the state must prove
beyond a reasonable doubt that <insert the concluding summary from the
instruction for the underlying crime>, and that the <insert name of child
or person taken> was (exposed to a risk of <insert type of risk> /
taken, enticed, or detained out of this state).

If you unanimously find that the state
has proved beyond a reasonable doubt each of the elements of the crime of
custodial interference in the first degree, then you shall find the defendant
guilty. On the other hand, if you unanimously find that the state has failed to
prove beyond a reasonable doubt any of the elements, you shall then find the
defendant not guilty.